Executive Director, Quality, Infection Prevention

4 weeks ago


Hyannis, United States Cape Cod Healthcare Full time

PURPOSE OF POSITION:

The Executive Director Quality, Infection Prevention and Regulatory Preparedness is responsible for providing strategic leadership and direction in all quality, patient safety, regulatory compliance, and infection prevention for the organization ensuring safe patient care.


PRIMARY DUTIES AND RESPONSIBILITIES:

  • Directs collaborative efforts with physicians, revenue cycle, payers, patients, and their families, to incorporate evidence-based practices and appropriate use of resources.
  • Accountable to ensure the hospital maintains adherence to all regulatory requirements. Manages regulatory site surveys, creates plans of correction as needed, and ensures compliance to plans of correction.
  • Coordinates, evaluates, updates, and disseminates all data and educational information as it relates to regulatory bodies such as the Joint Commission and Massachusetts Department of Public Health (DPH).
  • Manages all data and reporting for quality metrics and creates improvement plans to increase publicly reported ratings such as Leap Frog and Star Ratings. Manages submissions as needed (Ex: Leap Frog)
  • Facilitates the Performance Improvement and Patient Safety Committee.
  • Coordinates the medical staff quality programs.
  • Communicates effectively with Hospital leadership in the development of day-to-day and strategic goals.
  • Ensure that appropriate departments are updated regarding new standards, policies, and procedures.
  • Oversees all National Patient Safety Goals (NPSG) implementation and ongoing compliance.
  • Establish a coordinated tracer methodology ongoing process and will periodically perform tracers.
  • Facilitates Failure Modes and Effects Analysis (FMEA's) for the organization.
  • Promotes an environment of transparency with employees and nursing department.
  • Actively participates in review and identification of opportunities of nurse quality indicators as measured by The National Database of Nursing Quality Indicators (NDNQI) at individual department level collaborating with nurse managers.
  • Benchmarks performance against national best practices.
  • Financial stewardship: monitors, controls, and is accountable for maintaining departmental costs within budgeted allocations.
  • Must be able to manage multiple competing priorities and maintain calm demeanor in stressful environment.
  • Proficiency with computers and clinical applications.
  • Ability to effectively negotiate with patients, families, internal and external providers of patient care services.
  • Consistently provides service excellence to all patients, family members, visitors, volunteers, and co-workers.
  • Challenges current working practices, identifies process improvement opportunities and presents recommendations and solutions to management. Engages and commits to the organization’s culture of continuous improvement by actively participating, supporting, and promoting CCHC Pillars of Excellence.


EDUCATION/EXPERIENCE/TRAINING:

  • BSN degree or equivalent education and years of experience, Master’s degree in nursing (MSN) or related field (MBA/MHA) preferred
  • MA State Registered Nurse License
  • Certified Professional in Healthcare Quality (CPHQ) is preferred.
  • Minimum of five (5) years in Performance Improvement/Quality Management and Infection Prevention.
  • Provided leadership for at least 2 successful joint commission surveys utilizing tracer methodology.
  • Working knowledge of regulatory agency standards and requirements
  • Must possess excellent oral, written and analytical skills. Effective problem solving, conflict management and organizational skills.
  • Clinical competence and the ability to establish respect and rapport with peers, staff, physicians, and administration within Cape Cod Healthcare.


Schedule Details: Full time, Monday-Friday, occ. eves, weekends, and holidays



  • Hyannis, United States Maplewood Mill Pond LLC Full time

    Resident Services Director, RN or LPN Want to know what makes our employees eager about going to work every day? The people we serve. Being a part of Maplewood requires passion and a desire to help others. Each employee has the ability to touch the hearts of all our seniors and be a part of something bigger than themselves. It's not just a job. It's an...

  • Director of Nursing

    2 days ago


    Hyannis, United States Brookdale Cape Cod Full time

    Overview: **_ Voted by Newsweek in 2024 as one of America's Greatest Workplaces for Diversity_** **About the Director of Nursing Position** As Director of Nursing at Brookdale, you will utilize your leadership qualities to inspire, lead and manage the overall operation of the clinical team to provide the highest quality of care and services for our...


  • Hyannis, United States Cape Cod Hospital Full time

    Purpose of Position Provides evaluation and follow up patient care and conducts selected health services for psychiatric patients under the direction of the Executive Director. Description Responds to psychiatric emergencies utilizing training in management of aggressive behaviors. Demonstrates skills and takes initiative in preventing situations from...


  • Hyannis, United States Bay Cove Human Services Full time

    Bay Cove Human Services' mission is to partner with people to overcome challenges and realize personal potential. Bay Cove pursues this mission by providing individualized and compassionate services to people facing the challenges associated with developmental disabilities, mental illness, substance use disorders, and homelessness at more than 175 program...


  • Hyannis, United States ADDP Full time

    Director of Human Resources - Cape Abilities - Hyannis, MA Full Time 40 Hours Provides leadership, vision, development, and overall management of all Human Resource activities and staff and reinforces the Agency’s culture, values, and mission through the delivery of HR programs and services. Develop innovative approaches and ideas for all aspects of HR....

  • Lifestyle Director

    2 days ago


    Hyannis, United States Maplewood Mill Pond LLC Full time

    Want to know what makes our employees eager about going to work every day? The people we serve. Being a part of Maplewood requires passion and a desire to help others. Each employee has the ability to touch the hearts of all our seniors and be a part of something bigger than themselves. It’s not just a job. It’s an extraordinary life. Maplewood Senior...

  • Lifestyle Director

    6 days ago


    Hyannis, United States Maplewood Mill Pond LLC Full time

    Want to know what makes our employees eager about going to work every day? The people we serve. Being a part of Maplewood requires passion and a desire to help others. Each employee has the ability to touch the hearts of all our seniors and be a part of something bigger than themselves. It’s not just a job. It’s an extraordinary life. Maplewood Senior...


  • Hyannis, United States CapeAbilities Full time

    Cape Abilities, Inc. Director of Individual Supports Hyannis , Massachusetts Apply Now The Director of Individual Supports offers personalized guidance, steadfast support, and exemplary role modeling for individuals with diverse developmental/intellectual disabilities and acquired brain injuries. They oversee the cultivation of essential life, social, and...


  • Hyannis, Massachusetts, United States Olesky Associates, Inc Full time

    Medical Director, Inpatient Substance Use, Primary Care and Behavioral Health An award winning nationally accredited non-profit leader in the prevention, treatment, and recovery of mental health and substance use disorders is seeking a Medical Director (Family/ Internal Medicine) for an Inpatient Unit. The inpatient unit offers a full, end-to-end continuum...


  • Hyannis, United States Cape Cod Maritime Museum Full time

    **Administrative Manager** **Full-time (35-40 hours per week, salaried $50,000 per annum)** **Availability Some Evenings & Weekends Preferred (for occasional events)** **Position to Begin Training June 24th** The Administrative Manager will work closely with the Executive Director, Communications Manager, Membership Director, and staff to manage...


  • Hyannis, United States CapeAbilities Full time

    GENERAL SUMMARY The Director of Individual Supports offers personalized guidance, steadfast support, and exemplary role modeling for individuals with diverse developmental/intellectual disabilities and acquired brain injuries. They oversee the cultivation of essential life, social, and recreational skills, facilitate community integration, ensure healthcare...


  • Hyannis, United States Cape Air Full time

    Job DescriptionJob DescriptionSUMMARY:This a part-time position that executes a route and region-specific marketing strategy using a variety of promotions, sponsorships, philanthropy, memberships and communications to build community support for continued Cape Air service and increase route revenue and/or passengers.PRIMARY RESPONSIBILITIES:Collaborate with...


  • Hyannis, United States Cape Air Full time

    Job DescriptionJob DescriptionSUMMARY:This a part-time position that executes a route and region-specific marketing strategy using a variety of promotions, sponsorships, philanthropy, memberships and communications to build community support for continued Cape Air service and increase route revenue and/or passengers.PRIMARY RESPONSIBILITIES:Collaborate with...


  • Hyannis, United States Barnstable Public Schools Full time

    Barnstable Public SchoolsSchool Nurse (Float) JOB GOAL: To support the Director of Health Services and building-based school nurses throughout the district in providing health services to the students of Barnstable Public Schools. QUALIFICATIONS: Valid license to practice as a Registered Nurse in Massachusetts A bachelor's or master's degree of nursing...


  • Hyannis, United States Cape Abilities Full time

    Job DescriptionJob DescriptionGENERAL SUMMARY The Assistant Director Residential Homes (ADR) assumes overall coordination, leadership, and responsibility for the day-to-day operations of three or more residential group homes. The ADR will also supervise and mentor their assigned Residential Program Managers, helping them to improve their practices and meet...


  • Hyannis, United States Cape Abilities Full time

    Job DescriptionJob DescriptionGENERAL SUMMARY The Assistant Director Residential Homes (ADR) assumes overall coordination, leadership, and responsibility for the day-to-day operations of three or more residential group homes. The ADR will also supervise and mentor their assigned Residential Program Managers, helping them to improve their practices and meet...


  • Hyannis, United States The Vascular Care Group Full time

    OverviewThis role is generally responsible for providing clinically relevant information to assist the physician with the diagnosis and treatment of vascular patients. All activities should be performed consistent with the Vascular Sonographer's education and training, and in accordance with facility policies and procedures and applicable professional...


  • Hyannis, United States Cape Abilities Full time

    Job DescriptionJob Description GENERAL SUMMARY The Director of Individual Supports offers personalized guidance, steadfast support, and exemplary role modeling for individuals with diverse developmental/intellectual disabilities and acquired brain injuries. They oversee the cultivation of essential life, social, and recreational skills, facilitate community...


  • Hyannis, United States Cape Cod Healthcare Full time

    PURPOSE OF POSITION:Works with appropriate stakeholders to maintain responsibility for the Cape Cod Healthcare (CCHC) workers' compensation (WC) program focusing on claims, case, and reserve management as well as data analysis and collaboration for preventive programs. Collaborates with the CCHC team, employees, managers, providers, attorneys, claims...


  • Hyannis, United States The Vascular Care Group Full time

    Job DescriptionJob DescriptionOverviewThis role is generally responsible for providing clinically relevant information to assist the physician with the diagnosis and treatment of vascular patients. All activities should be performed consistent with the Vascular Sonographer's education and training, and in accordance with facility policies and procedures...